|Year : 2016 | Volume
| Issue : 3 | Page : 122-125
The role of methylene blue in laparoscopic sleeve gastrectomy
Osama A Abdul Raheem MD 1, Mohamed Yousef1, Abd-EL-Aal Ali Saleem Mohran1, Hassan A Abdallah1, Asmaa Gaber2
1 Department of General Surgery, Faculty of Medicine, Aswan University, Aswan, Egypt
2 Department of General Surgery, Faculty of Medicine, South Valley University, Qena, Egypt
|Date of Submission||23-Jul-2016|
|Date of Acceptance||24-Jul-2016|
|Date of Web Publication||15-Feb-2017|
Osama A Abdul Raheem
Department of General Surgery, Faculty of Medicine, Aswan University, Aswan
Source of Support: None, Conflict of Interest: None
Methylene blue (MB) is a molecule that has been playing important roles in microbiology and pharmacology for some time. It has been widely used to stain living organisms and to treat methemoglobinemia, and lately it has been considered as a drug for photodynamic therapy. Nowadays, it is used in the treatments of basal cell carcinoma, Kaposi’s sarcoma, melanoma, and virus and fungal infections. MB has low toxicity and no adverse effects.
Patients and methods
This study was conducted in Aswan University on female and male patients. Our study was done on 70 patients, who had an average age of 29.8 years, with minimum of 25 years and maximum of 35 years. Patients were studied preoperatively with complete investigations, a multidisciplinary workup including specialist counseling (internal medicine, psychiatry, and anesthesiology), and complete performance status evaluation. Patients were well informed about the surgical procedure, with all potential advantages and possible complications and adverse effects. Then they were proceeded to laparoscopic sleeve gastrectomy and the uses of intraoperative MB to confirm any leaks from the stapler line. Postoperative data regarding fever, tachycardia, vomiting, abdominal pain and distention, abdominal ultrasound for any collection, and complete blood count were recorded. All the above data were collected and analyzed to obtain statistically relevant results.
Apart from mild abdominal pain and tenderness, and low-grade fever, no collection appeared clinically or by ultrasound examination in all cases. All patients received oral fluids on the third postoperative day, and no vomiting developed. White blood cell count was done for all patients, and they were normal except five patients who developed chest infection with low-grade fever which improved with antibiotic. Before discharging the patients, abdominal ultrasound was done for all, and no collection of fluid appeared.
Intraoperative MB usage is a safe and effective technique in detecting gastric leak during laparoscopic sleeve gastrectomy.
Keywords: methylene blue, obesity, sleeve gastrectomy
|How to cite this article:|
Abdul Raheem OA, Yousef M, Saleem Mohran AEA, Abdallah HA, Gaber A. The role of methylene blue in laparoscopic sleeve gastrectomy. Al-Azhar Assiut Med J 2016;14:122-5
|How to cite this URL:|
Abdul Raheem OA, Yousef M, Saleem Mohran AEA, Abdallah HA, Gaber A. The role of methylene blue in laparoscopic sleeve gastrectomy. Al-Azhar Assiut Med J [serial online] 2016 [cited 2017 Sep 24];14:122-5. Available from: http://www.azmj.eg.net/text.asp?2016/14/3/122/200149
| Introduction|| |
Obesity is a common disease affecting adults and children. The incidence of obesity is increasing nowadays. Laparoscopic sleeve gastrectomy (LSG) is a relatively new and effective procedure for weight loss of large magnitude and correction of comorbidities, with excellent short-term and long-term outcomes .
Obesity is a condition in which individuals have excessive fat deposits and is defined as a BMI of greater than 30, to a point where the person is at an increased risk of morbidity and mortality . Obesity is measured by the BMI, a measurement calculated by dividing a person’s weight (kg) by their height (cm). People are considered to be underweight at a BMI of 18 or less, normal at a BMI of 18.5 to 24.9, overweight at a BMI of 25 to 29.9, obese at a BMI of 30 or more, morbidly obese to severely obese at a BMI of 40 or more, and super obese at a BMI of 50 or more .
LSG is a feasible option in the management of morbid obesity. Sleeve gastrectomy was first performed laparoscopically by Ren et al. . Gastric leak is one of the most serious complications of LSG. Leak is defined as ‘the leak of luminal contents from a surgical join between two hollow viscera’. A leak may also represent a gastrointestinal leak in a suture line around the organ. Luminal contents may emerge through the wound or at the drain site, or they may collect near the anastomosis site . It occurs in up to 5% of patients following LSG .
Several classifications exist based on the radiologic findings and time of diagnosis. Based on the upper gastrointestinal contrast study, gastric leak can be classified into two types . Type I or subclinical leak is controlled either through a surgical drain or through a fistulous tract into the abdominal or chest cavity. Type II or clinical leak is a disseminated leak with diffusion of the contrast into the abdominal or chest cavities .
Based on the time of diagnosis, gastric leaks are classified as early leaks appearing 1–3 days after surgery, intermediate leaks appearing 4–7 days after surgery, and late leaks appearing at least 8 days after surgery ,. Gastric leaks can be diagnosed either incidentally on a routine upper gastrointestinal series performed postoperatively without any clinical signs or during exploratory laparoscopy/laparotomy performed owing to unexplained tachycardia .
Treatment options include conservative or surgical management. This depends on the patient’s hemodynamic condition and on physical and radiologic findings. In the absence of hemodynamic instability and physical findings suggestive of peritonitis, conservative management may be initiated. This entails fluid resuscitation; initiation of intravenous antibiotics, nothing by mouth; percutaneous drainage of intra-abdominal collections (if drainable); and intraluminal stenting .
Some investigators have successfully managed delayed gastric leaks with drainage (either surgical or percutaneous), establishment of a feeding route (enteral or parenteral), and placement of gastric stents for ∼2–4 weeks. Other investigators have also used intraluminal stents for the management of gastric leaks ,. Himpens and colleagues reported their experience in the management of 29 patients with gastric leak after sleeve gastrectomy with stenting. These investigators left the stents in situ on an average of 7 weeks. Immediate success was observed in 19 patients with the placement of the first stent, whereas five patients required placement of a second stent. However, two patients had persistent leaks requiring a surgical intervention ,.
| Patients and methods|| |
This study was conducted in Aswan University on female and male patients. Our study was done on 70 patients who were of an average age of 29.8 years, minimum of 25 years and maximum of 35 years. The patients had a mean age of 41.5 years and a BMI of 45.4 kg/m2. Patients with different degrees of obesity underwent LSG. During surgery, each patient received methylene blue (MB) by way of nasogastric tube with no drain being placed.
Patients were studied preoperatively with complete investigations, complete blood count, liver functions test, kidney function test, coagulation profile, abdominal ultrasound and pelvis, upper endoscopic examination, urine 24 h cortisone level, thyroid function test, and a multidisciplinary workup including specialist counseling (internal medicine, psychiatry, and anesthesiology) and complete performance status evaluation. Patients were well informed about the surgical procedure, with all potential advantages and possible complications and adverse effects. Operative and postoperative data were recorded, which included fever, tachycardia, vomiting, abdominal pain and distention, abdominal ultrasound for detection of any collection of fluid, and complete blood count.
All the above data were collected and analyzed to obtain statistically relevant results.
The patients are placed in a supine position with the arms spread apart. Pneumoperitoneum is achieved using a closed technique with a Veress needle placed in the left subcostal area of the abdomen. A 10-mm pore is placed in the supraumbilical for camera. An additional 15-mm port is placed in the left midabdomen to pass the stapler. Finally, two additional 5-mm ports are placed in the left and right upper quadrants of the abdomen. The left lobe of the liver is retracted medially using a Nathanson retractor placed in the subxiphoid area.
The stomach is decompressed at the beginning of the operation by placing an orogastric tube. The surgeon stands between the legs of the patient. The first assistant stands to the right of the patient for camera. The second assistant stands to the left of patient. The angle of His is taken down bluntly using the Goldfinger dissector (Ethicon Endo-Surgery; Johnson, USA), exposing the left crus of the diaphragm. Dissection is started ∼6 cm proximal to the pylorus by taking down the gastrocolic ligament using the Harmonic Scalpel (Ethicon Endo-Surgery). Dissection is carried out proximally toward the short gastric vessels. This releases attachments to the greater curvature of the stomach and gastric fundus. The orogastric tube is then removed and replaced by a 50-Fr bougie placed in the stomach by the anesthesiologist and guided laparoscopically to sit in the lesser curvature of the stomach just distal to the pylorus. A 60-mm Endo GIA Tri-Stapler (Covidien, USA) is then used to divide the stomach. We use two black cartridges initially to divide the distal stomach, starting 6 cm proximal to the pylorus. Next, 4–6 60-mm purple cartridges are used to complete the division of the remainder of the stomach. The MB was injected through the bougie, and when it is confirmed that there is no leakage from the stapler line, the bougie is then removed. The specimen is then taken out of the abdominal cavity through the 15-mm port. Only the skin is closed.
| Results|| |
There were 70 patients between July 2014 and July 2015 who underwent LSG. Early postoperative period was observed for the following signs: fever, tachycardia, vomiting, leukocytosis, abdominal pain and distension, and abdominal ultrasound during the period of admission, which was 1 week. All patient developed mild abdominal pain without tenderness and rigidity and received a single dose of NSAIDs. All patients received oral fluids on the third postoperative day, and no vomiting developed. White blood cell count was done for all patients, and all patients were normal except for five patients who developed chest infection with low-grade fever, which improved with antibiotic. These patients smoked and had past history of bronchial asthma. Before discharging the patients, abdominal ultrasound was done for all, and no collection of fluid appeared.
Pain and medication
Sleeve gastrectomy is usually not a painful procedure. A supply of soluble pain killers is given to the patients to take home; these should be taken regularly for the first few days. The patients are advised to gradually reduce the number of tablets if there is no pain. The soluble tablets should be allowed to stop fizzing in the water before consuming. The patients are also prescribed an antiacid sublingual tablet (lansoprazole; FasTab) to be taken daily for at least 3 months after the surgery.
If the patients have been taking medications to control their blood pressure or diabetes, they would be reviewed before their discharge. In most cases, these medications can be reduced or sometimes stopped all together.
At the time of discharge, the patients were advised to not take any large tablets for first 2 weeks as they may get stuck and damage the staple line. All tablets have to be crushed or taken in soluble form. If in doubt, the surgeon should be contacted.
| Discussion|| |
LSG is becoming a very common surgical procedure for treating morbid obesity. Advantages of LSG include minimal complications, avoidance of foreign material, maintain gastrointestinal continuity, no malabsorption, and can be perform with other operative procedures. The most common surgical complications are staple-line bleeding, strictures commonly at the middle or distal remaining part of the stomach, and the most dangerous complication being staple-line leaks ,.
Gastric leak mostly occurs along the proximal third of the stomach, close to the gastroesophageal junction owing to high intragastric pressure in this area with decreased peristaltic activity and ischemia ,.
Csendes et al.  proposed classification for gastric leaks based on the time of appearance after surgery, magnitude or severity, and site of bleeding. The three categories are early leaks that occur 1–4 days after surgery, intermediate leaks that occur 5–9 days after surgery, and late leaks that occur at day 10 or later after surgery . The severity of gastric leaks is divided into class I: subclinical appearing as a local leak without spillage or dissemination and class II: leaks resulting in dissemination or diffusion of gastric content into the abdominal or pleural cavity . It has been noted that extraluminal gastric leaks, if not managed properly, may lead to gastric-cutaneous fistula, peritonitis, abscess, sepsis, systemic organ failure, and finally death .
The cause of a gastric leak is not clear but may be because of failure of normal healing process of tissue. There is a general agreement that local risk factors for development of leak are impaired suture line healing owing to staple dehiscence, poor blood supply, and infection. These risk factors lead to decrease in oxygen and ischemia to the tissue ,. Some suggests that the actual etiology of leaks is owing to some form of thermal damage upon tissue from the laparoscopic tools. Baker claims two main types of gastric leaks: ischemic leaks that appear between 5 and 6 days after operation and mechanical tissue damage that tends to appear within 2 days after surgery . Gastric leak may be difficult in diagnosis, as the presentation can be variable from asymptomatic to severe septic shock. Common symptoms may be related to presence of sepsis as fever, tachycardia, tachypnea, leukocytosis, abdominal pain, and peritonitis . Hamilton et al.  suggest that tachycardia 120 bpm may be an early diagnostic sign of a gastric leak.
There is no current protocol to manage gastric leak. However, from the literature, there is an agreement among the authors that timing of diagnosis is important in deciding the type and urgency of treatment. Early diagnosis of gastric leak (3 days) has a better prognosis when treated immediately surgically: either laparoscopic or open washout, drainage placement, and resuturing of leak if tissue is still healthy and there is no inflammation. Late gastric leak can be treated conservatively, with enteral nutrition, high-dose proton pump inhibitor to decrease the gastric secretion and avoidance of stress ulcer, placement of drain, and good antibiotics ,.
According to the First International Consensus Summit for Sleeve Gastrectomy, treatment of leak included early resuturing of leak site, drainage (CAT or open), endoscopic clipping, and persisting fistula requiring fibrin glue, stents, Roux-loop, and even total gastrectomy . Bege et al.  have suggested an approach to endoscopic management of postbariatric surgery fistula complications. It consists of three stages of leak: first stage consists of lavage and drainage of the perianastomotic fluid (natural endoscopic transluminal endoscopic surgery), second stage consists of fistula diversion by placement of a covered stent, and finally closure of fistula by clips or glue (either fibrin or cyanoacrylate) .
It is advisable to compress the tissue being manipulated and to keep the position to allow sufficient time for fluids to exit and for the staples to be placed with ease; gentle compression for ∼10 s should be enough time to reduce the trauma level to the tissue .
We concluded that LSG is gaining popularity for the treatment of morbid obesity, and using MB intraoperatively is an effective method to detect the leak before starting oral fluid.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Gagner M, Chu CA, Quinn T, Feng JJ, Pomp A, Korgaonkar NM et al.
Two-stage laparoscopic biliopancreatic diversion with duodenal switch: an alternative approach to super-super morbid obesity. Sur Endosc 2003; 16:S069.
Deitel M, Crosby R, Gagner M. The first international consensus summit for sleeve gastrectomy (SG), New York City, October 25–27, 2007. Obes Surg 2008; 18:487–496.
Ren CJ, Patterson E, Gagner M. Early results of laparoscopic biliopancreatic diversion with duodenal switch: a case series of 40 consecutive patients. Obes Surg 2000; 10:514–523.
Bruce J, Krukowski ZH, Al-Khairy G, Sheridan WG, Lowndes RH, Young HL. Systematic review of the definition and measurement of anastomotic leak after gastrointestinal surgery. Br J Surg 2001; 88:1157–1168.
Moon Han S, Kim WW, Oh JH. Results of laparoscopic sleeve gastrectomy (LSG) at 1 year in morbidly obese Korean patients. Obes Surg 2005; 15:1469–1475.
Burgos AM, Braghetto I, Csendes A, Maluenda F, Korn O, Yarmuch J et al.
Gastric leak after laparoscopic-sleeve gastrectomy for obesity. Obes Surg 2009; 19:1672–1677.
Csendes A, Diaz JC, Burdiles P, Braghetto I, Maluenda F, Nava O, Korn O. Classification and treatment of anastomotic leakage after extended total gastrectomy in gastric carcinoma. Hepatogastroenterology 1990; 37: 174–177.
Csendes A, Burdiles P, Burgos AM, Maluenda F, Diaz JC. Conservative management of anastomotic leaks after 557 open gastric bypasses. Obes Surg 2005; 15:1252–1256.
Csendes A. Conservative management of anastomotic leaks. Obes Surg 2006; 16:375–376.
Kolakowski S, Kirkland ML, Scuricht AL. Routine postoperative upper gastrointestinal series after Roux-en-Y gastric bypass. Arch Surg 2007; 142:930–934.
Márquez MF, Ayza MF, Lozano RB, Morales Mdel M, Díez JM, Poujoulet RB. Gastric leak after laparoscopic sleeve gastrectomy. Obes Surg 2010; 20:1306–1311.
Himpens J, Dapri G, Cadière G. A prospective randomized study between laparoscopic gastric banding and laparoscopic isolated sleeve gastrectomy: results after 1 and 3 years. Obes Surg 2006; 16:1450–1456.
Oshiro T, Kasama K, Umezawa A, Kanehira E, Kurokawa Y. Successful management of refractory staple line leakage at the esophagogastric junction after a sleeve gastrectomy using the HANAROSTENT. Obes Surg 2010; 20:530–534.
Simmons R, Thevarajah S, Brennan MB, Christos P, Osborne M. Methylene blue dye as an alternative to isosulfan blue dye for sentinel lymph node localization. Ann Surg Onco 2003; 10:242–247.
Casella G, Soricelli E, Rizzello M, Trentino P, Fiocca F, Fantini A, Salvatori FM et al.
Nonsurgical treatment of staple line leaks after laparoscopic sleeve gastrectomy. Obes Surg 2009; 19:821–826.
Csendes A, Braghetto I, León P, Burgos AM. Management of leaks after laparoscopic sleeve gastrectomy in patients with obesity. J Gastrointest Surg 2010; 14:1343–1348.
Carucci LR, Turner MA, Conklin RC, DeMaria EJ, Kellum JM, Sugerman HJ. Roux-en-Y gastric bypass surgery for morbid obesity: evaluation of postoperative extraluminal leaks with upper gastrointestinal series. Radiology 2006; 238:119–127.
Baker RS, Foote J, Kemmeter P, Brady R, Vroegop T, Serveld M. The science of stapling and leaks. Obes Surg 2004; 14:1290–1298.
Hamilton EC, Sims TL, Hamilton TT, Mullican MA, Jones DB, Provost DA. Clinical predictors of leak after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Sur Endosc 2003; 17:679–684.
Bege T, Emungania O, Vitton V, Ah-Soune P, Nocca D, Noël P et al.
An endoscopic strategy for management of anastomotic complications from bariatric surgery: a prospective study. Gastrointest Endosc 2011; 73:238–244.